Injury Questionnaire

LA OWCA Second Injury Board Knowledge Questionnaire

The following questionnaire should only be completed by individuals that have been hired for employment. Your employer may ask that you complete this questionnaire following your initial hire and periodically thereafter. The questionnaire may be used in the establishment of prior knowledge for the purpose of obtaining Second Injury Fund Relief from the Second Injury Board. The Second Injury Board may reimburse your employer for workers' compensation claims that meet criteria should you become injured on the job. This reimbursement in no way affects the benefits owed to you by your employer or their insurance company under the Louisiana Workers' Compensation Act, La. R.S. 23:1021-1361.
FAILURE TO ANSWER TRUTHFULLY AND/OR CORRECTLY TO ANY OF THE QUESTIONS ON THIS FORM MAY RESULT IN A FORGEITURE OF YOUR WORKERS COMPENSATION BENEFITS UNDER LA R.S. 23:1208.1.
EMPLOYER:
EMPLOYEE NAME: *

First Name Last Name
DATE OF BIRTH: *

Month Day Year
Date
SEX: *
SOCIAL SECURITY NUMBER: *
LAST 4 DIGITS
HOME ADDRESS: *

Street Address

Street Address Line 2

City State

Zip Code
PHONE NUMBER: *

Area Code Phone Number
Personal Email address: *
example@example.com

LA OWCA Second Injury Board Knowledge Questionnaire